For the first time ever, the Toronto Star is revealing a comprehensive database of almost 200 of the highest-billing doctors in the province, cracking open a $12-billion-a-year system that for decades has operated behind closed doors.
Seven years of Ministry of Health data identifies doctors whose annual billings to the Ontario Health Insurance Plan placed them in the Top 100 at least once between the fiscal years 2011-12 and 2017-18. That’s 194 of the 31,500 practising physicians in Ontario.
The data paints a picture not only of who is billing the most, but also the types of treatments for which they are billing.
The 35 million billing records were obtained by the Star after a series of Freedom-of-Information requests by health reporter Theresa Boyle, the first of which was filed five years ago in a push for greater transparency on how health-care dollars are spent.
The data, drilled down to patient level with identifying information stripped out, includes such granular detail as doctors’ total billings per year, number of patient visits, fee codes and billings for top procedures by cost and quantity.
The Star is publishing this searchable database online at thestar.com with a snapshot of the Top 100 rankings for the 2017-18 fiscal year appearing in the newspaper.
For context, it’s important to remember doctors’ billings do not represent take-home pay as physicians also have often significant overhead expenses for such things as equipment, rent and staff salaries that they pay for out of those billings.
Here is a guide to understanding the Star’s OHIP billing database.
What are fee codes and how do they work?
Ontario doctors are paid from OHIP in three main ways: patient-enrolment; alternative payment and fee-for-service. (Some doctors also have other sources of income.)
Most doctors get at least some of their compensation through fee-for-service payments — more popular with specialists, less so with family doctors. This model accounted for more than half — or $6.7 billion — of the roughly $12 billion the province spent on physician compensation in 2017-18.
Physicians who operate under this model bill OHIP for each service they provide using a unique fee code. It’s done on the honour system.
There are more than 8,000 fee codes contained in a public document called the OHIP Schedule of Benefits and Fees, for every procedure, test, and consultation a physician can do. Each fee code has a unique number, price and description. A Caesarean section, for example, is priced at $579.80, or the removal of stitches under general anesthesia is pegged at $41.25.
By looking at the database, readers can see doctors’ top fee codes. The descriptions are heavy on medical jargon. But by searching the fee code in the schedule of benefits you can get a sense of what procedures and tests a doctor performs the most.
The prices attached to fee codes have been set through negotiations between the Ontario Medical Association, which represents the political and economic interests of the province’s doctors, and the Ministry of Health and Long-Term care. This takes into account complexity and time.
What does “days worked” mean?
The “days worked” field counts dates a physician provided medical care to one or more patients during the fiscal year, which starts April 1 and ends March 31.
For certain doctors, this number is very high. GTA radiologist Alexander Hartman, who was the number five biller in 2017-18, at about $4 million, billed for 364 days that year. When asked about it by the Star, his receptionist responded on his behalf that “his office is open 364 days a year and he typically works long hours and seven days per week.”
According to OMA president Sohail Gandhi, because of the way OHIP records billings for reading tests, the number of days a physician appears to have worked can be much higher than actual number of days worked. This is an issue for radiologists and sometimes cardiologists.
For example, if a patient is sent for a CT scan over the weekend or while a radiologist is on vacation, they will read the test results when they return to work. But when the radiologist submits billing to OHIP, the system automatically codes the work for the day the test was done — not the day the radiologist read the test results.
“If a physician works at night seeing patients either in the emergency room, obstetrics, etc., and the shift they work carries over midnight, the claims would show the physician working two days,” Gandhi added.
What does “patient visits” mean?
The “patient visits” field refers to how many patient interactions there were, per doctor, per fiscal year. Some of these could be for the same patient. Each patient has a unique ID number, but no identifying factors.
Can a doctor bill on behalf of other doctors?
Ministry of Health spokesperson David Jensen said doctors are expected to submit claims for services they actually performed, and should not submit claims for their work using another physician’s billing number.
But for certain procedures, the “most responsible physician” bills on behalf of a group of doctors using a team fee code.
For example, Dr. Yiu Wing (Paul) Tam bills on behalf of nine doctors using the chronic dialysis team fee. (Tam was the sixth highest biller in 2017 at about $3.9 million with 251 days billed.) As the medical director and chief of the Scarborough Dialysis Program, his billings represent the entire program, which serves 620 patients.
“Therefore, it would be inaccurate to describe the billings associated with my name as ‘earnings’ as they represent the revenue of the program itself, with its multiple sites and physicians providing around-the-clock care to our dialysis patients,” he wrote in statement to the Star.
Team fees cover certain services that might involve more than one doctor over a period of time.
Other examples of team fees include: home/self-care ventilation; palliative-care case management; monthly management fees for long-term care patients and monthly management for methadone maintenance, Jensen added.
Some “delegated care” provided by “qualified individuals” that doctors employ, can be claimed through OHIP by doctors, Jensen wrote. But there are “very specific rules,” about this. “For example, physicians who supervise residents can bill for work done by the resident” if they meet the requirements (provide the necessary supervision, etc.)
Many “high demand” specialties employ nurses, medical assistants and other staff, who provide as much care as they can within their training so that as many patients can be seen as possible, Gandhi added.
OHIP fees may include a bundle of services that cannot be separately billed, but are part of an overall assessment. Some portions may be delegated to other providers, but the physician is responsible for the care of patients, he wrote.
Why do some specialties show up more often than others?
Ophthalmology, cardiology and radiology, sometimes referred to as the “big three,” dominate the list of highest billers.
The Top 15 billing doctors from 2011 to 2018 include six ophthalmologists, two radiologists and three cardiologists. Two obstetrician-gynecologists, one anesthesiologist who was working in a private pain clinic and one internal medicine specialist make up the rest of the group.
According to the Canadian Institute for Health Information, an independent research organization, the average yearly gross clinical payment for ophthalmologists, who specialize in the diagnosis and treatment of eye disorders, is the highest of any specialty for which there is available data at $723,768 for 2016-17. Cardiologists, who diagnose and treat diseases of the cardiovascular system, have the third highest (after thoracic/cardiovascular surgeons) at $601,271.
The average yearly payment for radiologists, doctors who specialize in diagnosing and treating patients using medical imaging such as X-rays, CT scans, and MRIs, is not available. Many imaging and lab physicians are paid directly through hospital budgets and the data on payments is not complete.
Some physicians sub-specialize. For example, an ophthalmologist could specialize in the retina. This is one reason their billings might be higher than the specialty average.
Ophthalmology and cardiology involve a high volume of services, and also have a relatively high fee per service. Radiology has a lower average fee code price, but a very high volume of services, according to a 2016 Auditor General Report on physician billing.
Exact overhead costs are hard to pin down. They’re not tracked by the Ministry of Health, as doctors are independent contractors, spokesperson Jensen said.
The OMA says overhead can be up to 50 per cent of billings for certain specialties. Overhead can top 70 per cent for radiology, according to the Ontario Association of Radiologists. The provincial government, during arbitration hearings with the OMA, argued that overhead expenses were lower. For radiologists who work in hospitals, overhead costs for equipment and operating expenses are largely paid by hospitals, government negotiators said.
According to a 2012 article in Healthcare Policy, a Canadian peer-reviewed journal, doctors self-reported average overhead ranging from 12.5 per cent in emergency medicine to 42.5 per cent in ophthalmology.
Read more from the Star’s Operation Transparency series:
Why is my family doctor not on this list?
The database represents just a small fraction of the 31,500 physicians practising in the province.
According to the Auditor General’s report, there were roughly 14,100 family doctors in 2016. Family doctors represent only 15 per cent of the 194 highest billing physicians, with most of the top billers in that category working at pain or addiction clinics.
Some family doctors work on a fee-for-service model. But, according to the Auditor General’s 2016 report, about 60 per cent work under a patient-enrolment model, where they form group practices. Under this model, they have a roster of patients and are paid a fee based on the number of patients in the roster and a predetermined basket of services they provide. Fees vary based on the gender and age of the patient, but they’re paid the same fee whether they see the patient once a year, many times, or not at all. They can also receive fee-for-service payments, bonuses and other financial incentives on top of that for providing services outside the basket.
What’s excluded from the data?
Family health group premiums, telemedicine claims, payments under contracts, commercial labs, technical diagnostic fees and fees paid by other ministries are not included. Bulk adjustments (relating to the same issue, for the same physician, on more than 20 claims) are included in the total billed field.
One in a series of stories.
May Warren is a breaking news reporter based in Toronto. Follow her on Twitter: @maywarren11
Theresa Boyle is a Toronto-based reporter covering health. Follow her on Twitter: @theresaboyle